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Lr'm( 6zo�. <br /> Burnett County Office of Zoning Administrator Q1 T o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 = 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as N 1� <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m C y _ <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin 3. a ;U/tl <br /> .... . �... .............. <br /> ............................ <br /> .......... .......... .Z' <br /> OWNER (please p, <br /> Q CONTRACTOR or SURVEYOR or AGENT a <br /> ..�..... .. . .y .............................. ............................................................ ...... ..... .. � <br /> ADyDESSSADDRESS 'N1` <br /> ..1.[.t�Gf•.5� ..........//Sl..�..-.,+.........S. .Y........... <br /> ADDRESS ADDRESS <br /> 9W..S�/. .............................. ............................................................................................ o <br /> PHO . ........................................... PHONE <br /> PLER WELL DRILLER [ i <br /> :Y O <br /> .......... <br /> ......... . .............................................................................. .AD......DRESS........................................................................... <br /> ADDRESS . m G) <br /> Nj <br /> C. n p <br /> .............. O <br /> ........................................................................................... .PNO......N- ................................................................... ri <br /> PHONE E Z <br /> DESCRIPTION 4. Sanitary Facilities: <br /> No. Bathrooms ` <br /> 1. Work: 2. New Building Details """"" <br /> New Building Type No. Bedrooms RN :� <br /> Addition ......, r�'►".> Septic Tank Size Gals. ........ tla <br /> '✓� <br /> .... ..... ... .............. ............p............. r� <br /> Sanitary Size ..�..�..... ft. x .1 ..... ft. """"" <br /> '�....' ' <br /> Filling/Grading ,......... Height............. Stories .... ....... .. 4a. Absorption Field Site: <br /> Moving .......... Area �r..�kP..Y 'te.......12..�p�.�. Soil Type .................................... <br /> Slope .......................................... ° <br /> Mobile Home Sl <br /> y <br /> Privy .l.`.... 3. Use (describe exactly,(1 -Tamil` Pere. Rate ................................... <br /> Well ... ... home,garage, motel, etc.) Dry Well ..........Seepage Trench ...I...... <br /> C� ' <br /> Subdivision .......... Il. ' <br /> .................................................... <br /> Camping Unit .......... .................................................... Privy .......... I <br /> Seepage Bed ......... <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A_ Include road yJOF <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- vv O. <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING II <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. Q 0 <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... <br /> O <br /> m <br /> N <br /> 3 <br /> T "A <br /> 0 <br /> 3ay,G o <br /> �_o' <br /> � N roc, < y m Z <br /> < N <br /> j <br /> /GO p25, D. a m <br /> Z C) 25. . n � 21 <br /> 0 <br /> Ft =� <br /> �UW& �F <br /> Signature of Owner or Agent Date a <br /> X <br /> RemarksCX .......................................................................................... m RI <br /> u <br /> ........................................................................................................... ... ......... C . mn <br /> Inspection Date /—.2 14'........ ..... .. ....�. i'O w . o Pri m <br /> �-��insirartor <br /> ...........................Zo : N <br /> NOTE: A preliminary site inspection must be made nd site approval granted on all structures involving sanitar cilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will he issued. Do not purchase or Install a septic tank, do any Plumbing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not lie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />